Penile Myiasis Caused by Protophormia Terraenovae

Southeast Asian J Trop Med Public Health

PENILE MYIASIS CAUSED BY PROTOPHORMIA TERRAENOVAE

Noppadol Larbcharoensub1, Jinrapa Phothikasikorn2, Tanapat Pansawangwong3 and Ananchai Thaipratan3

1Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok; 2Department of Microbiology, Faculty of Science, Mahidol University, Bangkok; 3Yala Regional Hospital, Yala, Thailand

Abstract. Penile myiasis is a rare parasitic disease. We report here a case of a 59-year-old male with penile myiasis caused by Protophormia terraenovae. We give the clinical and pathological features of the patient and review the literature regarding penile myiasis. This is the first published clinicopathological report of penile myiasis caused by Protophormia terraenovae. Keywords: myiasis, penis, Protophormia terraenovae

INTRODUCTION Genital myiasis is uncommon. The pur- pose of this paper is to report the case of Myiasis is defined as the infestation penile myiasis and review the literature. of vertebrate hosts with the larval or pupal stage (maggots) of certain diptera flies, first described by Hope (1840). The CASE REPORT diagnosis is categorized as obligate, de- liberate egg-laying in or on tissues, or as A 59-year-old male patient from Yala facultative, opportunistic infestation by Province, Thailand presented to Yala re- occupying wounds for larval incubation gional hospital with a painful, foul-smell- (Burgess, 2003). Myiasis is uncommon ing ulcer on the glans penis. He is a laborer in Western countries when only single in a small farm and wears a short sarong cases have been reported and they usu- without underwear. He had no history ally involve patients who have traveled of underlying disease. He had a history to endemic countries. The nose, ears, of genital trauma two weeks before. The tracheostomy-wounds, face, oral cav- penis initially developed an ulcerative le- ity, and serous cavities are commonly sion on the prepuce; a few days later, the involved (Francesconi and Lupi, 2012). glans of penis developed an ulcer with exudate. The patient gave no history of fever or urinary symptoms. His tempera- Correspondence: Noppadol Larbcharoensub, Department of Pathology, Faculty of Medicine ture on presentation was 37ºC. Physical Ramathibodi Hospital, Mahidol University, 270 examination showed an ulcerative lesion Rama VI Road, Ratchathewi, Bangkok 10400, with central necrotic tissue and multiple Thailand. maggots crawling on the glans penis Tel: +66 (0) 2354 7277; Fax: +66 (0) 2354 7266 (Fig 1). The scrotum was intact. No in- E-mail: [email protected] guinal lymphadenopathy was detected.

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of the necrotic tissue was performed. The white maggots mea- suring 2 to 3 mm in diameter, 8 to 12 mm in length were col- lected and identified as Protophormia terraenovae (Fig 2). A day later, the wound was explored again and the remaining maggots came out spontane- Fig 1–Ulcerative lesion with central necrotic tissue and multiple mag- ously. The patient was gots crawling on the glans penis. treated with antibiotic dressings and intrave- nous ceftriaxone and metronidazole for one week. The patient was then discharged with 0.9% sodium chloride with iodopovidone dressings and oral cip- rofloxacin plus metho- nidazole antibiotics for two weeks. The patient was educated and mo- tivated with regards to personal hygiene. Three months follow- up demonstrated satis- Fig 2–Maggots of Protophormia terraenovae after removal from the factory and uneventful infected site. healing with resolute of the penile lesion.

The patient had a complete blood count DISCUSSION done which showed leukocytosis (white blood cell count: 10,600 cells/µl with Cutaneous myiasis is the infestation 86% of neutrophils). Urinalysis showed of the skin or mucosal membrane by larval increased white blood cells: 10-20/HPF. or pupal stage maggots of certain diptera The provisional diagnosis was penile ul- (Francesconi and Lupi, 2012). Wound my- cer with myiasis and lower urinary tract iasis affects skin with previous lesions and infection. Hemoculture and urine culture may consume both dead and living tissue were performed and revealed no growth (Francesconi and Lupi, 2012). Maggots are of aerobic bacteria. Surgical debridement seen in exposed areas in small neglected

Vol 49 No. 4 July 2018 601 Southeast Asian J Trop Med Public Health children, very old patients, the mentally and broad-spectrum antibiotics (Fran- retarded and bedridden patients who are cesconi and Lupi, 2012). The surgical treat- not able to take care of themselves (Sher- ment of myiasis consists of 1) the applica- man, 2000; Koifman et al, 2017). Homeless- tion of a toxic substance to the larva and ness, alcoholism, and peripheral vascular eggs, 2) the production of localized hy- disease are common cofactors (Sherman, poxia to force the emergence of the larva, 2000). Myiasis shows a male predilection and 3) the mechanical or surgical removal with a male:female ratio of 5.5:1 (Sher- of the maggots (Francesconi and Lupi, man, 2000). The lower extremity is the 2012). Myiasis-wounds are considered most common site of wound myiasis contaminated; therefore, proper wound (Sherman, 2000). Genital myiasis is an treatment is essential to prevent compli- uncommon occurrence and may involve cated infections. The wound should be male or female external genital organs cleansed and copiously irrigated with including the penis, scrotum, vulva and water, normal saline, hydrogen peroxide, vagina (Koifman et al, 2017). or dilute iodopovidone solution. Empiric Penile myiasis is rare. The larvae broad-spectrum antibiotic therapy should reported to cause penile myiasis are: Psy- be instituted as soon as possible, until the choda albipennis, Dermatobia hominis, Lucilia culture results could make adjusted the sericata, and Cordylobia anthropophaga (Pep- therapy. per et al, 2008; Nagy, 2012; Lyra et al, 2014; In conclusion, we describe here a rare Koifman et al, 2017). P. terraenovae has never case of penile myiasis caused by P. ter- been reported to cause penile myiasis. The raenovae in a male laborer. Penile myiasis various forms of P. terraenovae include must be considered in the differential the northern blowfly, blow fly, blue-bottle diagnosis of genital infectious diseases, fly and blue-arsed fly (Zhang et al, 2017). P. especially in patients with precarious terraenovae is commonly used for maggot hygiene, low socio-economic status and debridement therapy (Nuesch et al, 2002). urogenital problems (Sherman, 2000; The main concern with the use of maggot Koifman et al, 2017). Climatic changes debridement therapy is secondary infec- and global warming in recent years along tion (Nuesch et al, 2002). Contaminated with the rise in international travel and maggots of P. terraenovae are blamed for immigration have increased the likeli- bloodstream infections due to Providencia hood of spread of myiasis (Moshaver- stuartii and Candida albicans (Nuesch et al, inia and Kazemi Mehrjerdi, 2016). Public 2002). P. terraenovae is a vector of bacteria health education, combined with proper carrying colistin resistance genes (Zhang diagnosis and treatment, is crucial. et al, 2017). Despite promising benefits, maggot debridement therapy can be ACKNOWLEDGEMENTS threatened by an infectious complication. Genital myiasis may result in complica- The authors wish to thank Prut tions including: minor genital irritation, Saowaprut for his editorial corrections. genitourinary tract infection, auto-ampu- tation of the penis, and even death due to secondary infection (Koifman et al, 2017). REFERENCES The cornerstones of myiasis treatment Burgess IF. Myiasis: maggot infestation. Nurs are surgical debridement of necrotic tissue Times 2003; 99: 51-3.

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Francesconi F, Lupi O. Myiasis. Clin Microbiol tera: Calliphoridae). Ann Agric Environ Rev 2012; 25: 79-105. Med 2012; 19: 802-4. Hope FW. On insects and their larvae occasion- Nuesch R, Rahm G, Rudin W, et al. Clustering ally found in the human body. R Ent Soc of bloodstream infections during maggot Trans 1840; 2: 256-71. debridement therapy using contaminated Koifman L, Barros R, Schulze L, Ornellas AA, larvae of Protophormia terraenovae. Infection Favorito LA. Myiasis associated with pe- 2002; 30: 306-9. nile carcinoma: a new trend in developing Pepper WC, Benaragama SK, Kalsi JS, Karim countries? Int Braz J Urol Int Braz J Urol O. Cutaneous myiasis of Cordylobia anthro- 2017; 43: 73-9. pophaga. Urology 2008; 72: 65. Lyra MR, Fonseca BC, Ganem NS. Furuncu- Sherman RA. Wound myiasis in urban and lar myiasis on glans penis. Am J Trop Med suburban United States. Arch Intern Med Hyg 2014; 91: 217-8. 2000; 160: 2004-14. Moshaverinia A, Kazemi Mehrjerdi H. Canine Zhang J, Wang J, Chen L, et al. Housefly (Musca myiasis and its causal agents in northeast- domestica) and blow fly (Protophormia ter- ern Iran. Iran J Parasitol 2016; 11: 91-7. raenovae) as vectors of bacteria carrying Nagy V. Unusual presentation of the urogeni- colistin resistance genes. Appl Environ tal myiasis caused by Lucilia sericata (Dip- Microbiol 2017; 84: e01736-17.

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